Abstract
Background
Antihypertensive agents are among the most used therapeutic classes. The approach to the pharmacological treatment of hypertension is guided by international recommendations and adherence to treatment is known to result in effective prevention of cardiovascular risk.
Aim
The aim of this study was to evaluate the pattern of use of antihypertensive agents in general practice in terms of drug choice for the initial treatment of hypertension and adherence to treatments among newly recruited patients.
Methods
We collected the data of all antihypertensive drugs prescribed by general practitioners (GPs) and reimbursed between January 1998 and December 2002 by a Local Health Authority of Emilia Romagna (Ravenna district, 350,000 inhabitants). We selected subjects aged 40 years and older, permanently living in the area during the whole period of the study, who received their first prescription of antihypertensives between January and December 1999, with no prescription of antihypertensive agents in the previous year. For each patient, we documented the starting regimen and evaluated adherence to treatment in terms of persistence during the years (patients were defined persistent if they received at least one prescription per year) and in terms of daily coverage (patients were defined covered if they received an amount of drugs consistent with a daily treatment). Finally, switches or addition of other therapeutic classes during the 3-year period were identified.
Results
A cohort of 6,043 subjects receiving their first antihypertensive treatment in 1999 was obtained. Regarding the starting regimen, monotherapies with angiotensin converting enzyme inhibitors (n=1,597; 26%) or calcium channel blockers (n=1126; 19%) were the most frequently prescribed. Of the patients, 21% started with a drug combination regimen. Regarding adherence to treatment, 18% of the cohort received only one prescription throughout the 3 years, 13% received more than one prescription but stopped the therapy during the first year, 69% were persistent during the second year and 60% also during the third year. Only 34% were covered during the first year and 24% also during the second year, whereas only 20% of the patients resulted covered throughout the 3 years. Among persistent patients, 41% maintained the same antihypertensive regimen throughout the 3 years, 25% added other drugs to the initial treatment and 34% switched to completely different regimens.
Conclusions
Our findings reflect the lack of convergence among guidelines on the drug class(es) to be considered as first choice in the initial treatment of hypertension. Although an intervention in this field may have important implications in terms of cost savings, the ongoing debate does not allow us to draw definite conclusions on whether measures should be taken by the National Health Authority. However, the lack of adherence to antihypertensive treatment is undoubtedly a matter of concern for public health and should be addressed with appropriate interventions.
Similar content being viewed by others
References
Anonymous (2004) The use of drugs in Italy—National report 2003
Amery A, Birkenhager W, Brixko P, Bulpitt C, Clement D, Deruyttere M, De Schaepdryver A, Dollery C, Fagard R, Forette F (1985) Mortality and morbidity results from the European working party on high blood pressure in the elderly trial. Lancet 1:1349–1354
Dahlof B, Lindholm LH, Hansson L, Schersten B, Ekbom T, Wester PO (1991) Morbidity and mortality in the Swedish trial in old patients with hypertension (STOP-hypertension). Lancet 338:1281–1285
Anonymous (1979) Five-year findings of the hypertension detection and follow-up program. I. Reduction in mortality of persons with high blood pressure, including mild hypertension. Hypertension detection and follow-up program cooperative group. JAMA 242:2562–2571
Anonymous (1982) The effect of treatment on mortality in “mild” hypertension: results of the hypertension detection and follow-up program. N Engl J Med 307:976–980
Anonymous (1991) Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the systolic hypertension in the elderly program (SHEP). SHEP cooperative research group. JAMA 265:3255–3264
Gueyffier F, Boutitie F, Boissel JP, Pocock S, Coope J, Cutler J, Ekbom T, Fagard R, Friedman L, Perry M, Prineas R, Schron E (1997) Effect of antihypertensive drug treatment on cardiovascular outcomes in women and men. A meta-analysis of individual patient data from randomized, controlled trials. The INDANA investigators. Ann Intern Med 126:761–767
Turnbull F (2003) Effects of different blood-pressure-lowering regimens on major cardiovascular events: results of prospectively designed overviews of randomised trials. Lancet 362:1527–1535
Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones DW, Materson BJ, Oparil S, Wright JT Jr, Roccella EJ (2003) In: 7th report of the joint national Committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report. JAMA 289:2560–2572
August P (2003) Initial treatment of hypertension. N Engl J Med 348:610–617
Cifkova R, Erdine S, Fagard R, Farsang C, Heagerty AM, Kiowski W, Kjeldsen S, Luscher T, Mallion JM, Mancia G, Poulter N, Rahn KH, Rodicio JL, Ruilope LM, van Zwieten P, Waeber B, Williams B, Zanchetti A (2003) Practice guidelines for primary care physicians: 2003 ESH/ESC hypertension guidelines. J Hypertens 21:1779–1786
Williams B, Poulter NR, Brown MJ, Davis M, McInnes GT, Potter JF, Sever PS, Thom SM (2004) British hypertension society guidelines for hypertension management 2004 (BHS-IV): summary. BMJ 328:634–640
Trilling JS, Froom J (2000) The urgent need to improve hypertension care. Arch Fam Med 9:794–801
Jones JK, Gorkin L, Lian JF, Staffa JA, Fletcher AP (1995) Discontinuation of and changes in treatment after start of new courses of antihypertensive drugs: a study of a United Kingdom population. BMJ 311:293–295
Casiglia E, Mazza A, Tikhonoff V, Pessina AC (2002) Population-based studies improve outcome in hypertensive patients. Am J Hypertens 15:605–608
Mancia G, Pessina AC, Trimarco B, Grassi G (2004) Blood pressure control according to new guidelines targets in low- to high-risk hypertensives managed in specialist practice. J Hypertens 22:2387–2396
Montanaro N, Vaccheri A, Magrini N, Battilana M (1992) FARMAGUIDA: a databank for the analysis of the Italian drug market and drug utilization in general practice. Eur J Clin Pharmacol 42:395–399
WHO Collaborating Centre for Drug Statistics Methodology (Norway) (2000) ATC index with DDDs
Messerli FH (2000) Implications of discontinuation of doxazosin arm of ALLHAT. Antihypertensive and lipid-lowering treatment to prevent heart attack trial. Lancet 355:863–864
Anonymous (2002) Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT). JAMA 288:2981–2997
Motola D, Vaccheri A, Silvani MC, Poluzzi E, Bottoni A, De Ponti F, Montanaro N (2004) Pattern of NSAID use in the Italian general population: a questionnaire-based survey. Eur J Clin Pharmacol 60:731–738
Bloom BS (1998) Continuation of initial antihypertensive medication after 1 year of therapy. Clin Ther 20:671–681
Marentette MA, Gerth WC, Billings DK, Zarnke KB (2002) Antihypertensive persistence and drug class. Can J Cardiol 18:649–656
Degli Esposti L, Degli Esposti E, Valpiani G, Di Martino M, Saragoni S, Buda S, Baio G, Capone A, Sturani A (2002) A retrospective, population-based analysis of persistence with antihypertensive drug therapy in primary care practice in Italy. Clin Ther 24:1347–1357
Jones JK, Gorkin L, Lian JF, Staffa JA, Fletcher AP (1995) Discontinuation of and changes in treatment after start of new courses of antihypertensive drugs: a study of a United Kingdom population. BMJ 311:293–295
Caro JJ, Speckman JL, Salas M, Raggio G, Jackson JD (1999) Effect of initial drug choice on persistence with antihypertensive therapy: the importance of actual practice data. CMAJ 160:41–46
Caro JJ, Salas M, Speckman JL, Raggio G, Jackson JD (1999) Persistence with treatment for hypertension in actual practice. CMAJ 160:31–37
Payne KA, Esmonde-White S (2000) Observational studies of antihypertensive medication use and compliance: is drug choice a factor in treatment adherence? Curr Hypertens Rep 2:515–524
Monane M, Bohn RL, Gurwitz JH, Glynn RJ, Levin R, Avorn J (1997) The effects of initial drug choice and comorbidity on antihypertensive therapy compliance: results from a population-based study in the elderly. Am J Hypertens 10:697–704
Acknowledgements
We wish to thank the Local Health Authority of Ravenna, for supplying prescribing data. The study was supported by grants from the Regione Emilia Romagna and the University of Bologna. An institutional unrestricted grant was also received by Roche S.p.A.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Poluzzi, E., Strahinja, P., Vargiu, A. et al. Initial treatment of hypertension and adherence to therapy in general practice in Italy. Eur J Clin Pharmacol 61, 603–609 (2005). https://doi.org/10.1007/s00228-005-0957-y
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00228-005-0957-y